Abstract

Background:Although physiotherapy is frequently provided to patients in the ICU, its role has been questioned. The purpose of this systematic literature review, an update of one published in 2000, was to examine the evidence concerning the effectiveness of physiotherapy for adult, intubated patients who are mechanically ventilated in the ICU.

Methods:The main literature search was undertaken on PubMed, with secondary searches of MEDLINE, CINAHL, Embase, the Cochrane Library, and the Physiotherapy Evidence Database. Only papers published from 1999 were included. No limitations were placed on study design, intervention type, or outcomes of clinical studies; nonsystematic reviews were excluded. Items were checked for relevance and data extracted from included studies. Marked heterogeneity of design precluded statistical pooling of results and led to a descriptive review.

Results:Fifty-five clinical and 30 nonclinical studies were reviewed. The evidence from randomized controlled trials evaluating the effectiveness of routine multimodality respiratory physiotherapy is conflicting. Physiotherapy that comprises early progressive mobilization has been shown to be feasible and safe, with data from randomized controlled trials demonstrating that it can improve function and shorten ICU and hospital length of stay.

Conclusions:Available new evidence, published since 1999, suggests that physiotherapy intervention that comprises early progressive mobilization is beneficial for adult patients in the ICU in terms of its positive effect on functional ability and its potential to reduce ICU and hospital length of stay. These new findings suggest that early progressive mobilization should be implemented as a matter of priority in all adult ICUs and an area of clinical focus for ICU physiotherapists.

Figures in this Article

In most developed countries, physiotherapy is seen as an integral component of the multidisciplinary management of patients in ICUs. The role of physiotherapy in the ICU and the treatment techniques used by physiotherapists in the ICU vary considerably between units, depending on factors such as the country in which the ICU is located, local tradition, staffing levels, and expertise. In 2000, Stiller1 published a literature review investigating the effectiveness of physiotherapy for adult, intubated patients on mechanical ventilation in the ICU, covering a broad range of physiotherapy practice. This concluded that there was only limited evidence concerning the effectiveness of physiotherapy in this setting and identified an urgent need for further research to be conducted to justify the role of physiotherapy in the ICU. The review is frequently cited in articles concerning the role of physiotherapy in the ICU. Given that > 10 years have passed since its publication, what new evidence regarding the role of physiotherapy in the ICU has emerged? Does this new evidence confirm the role of physiotherapy in the ICU? Does it highlight areas of clinical practice where physiotherapy is most effective?

The objective of this systematic review was to update a summary of the evidence concerning the effectiveness of physiotherapy in the ICU. In keeping with Stiller,1 this review only considers the management of adult, intubated patients on mechanical ventilation.

Materials and Methods

Search Strategy and Study Selection

The PICOS (population, intervention, comparison, outcome and study design) criteria used in this study were deliberately broad to capture all relevant articles, requiring only that the population comprised adult (aged ≥ 18 years), intubated, mechanically ventilated patients being cared for in an ICU setting and that a physiotherapy intervention had been evaluated or discussed. No limitations were placed on study outcomes. All relevant clinical articles were included and systematic literature reviews, expert opinion papers, and surveys were also eligible for inclusion. The primary literature search was conducted using the PubMed database for articles published from January 1, 1999, to July 31, 2012, using the following search terms: “intensive care” AND “physiotherapy.” Additional searches were undertaken on PubMed using the terms “critical care” or “intensive care” AND “physical therapy,” “therapeutic exercise,” “functional training,” “exercise,” “exercise therapy,” “mobilisation,” “rehabilitation” or “ambulation.” Secondary searches, using the same time limitations and search terms, were undertaken on MEDLINE, CINAHL, Embase, Cochrane Library, and the Physiotherapy Evidence Database. Titles and abstracts generated by the search strategy were assessed for eligibility and full-text copies of articles deemed to be potentially relevant were retrieved. Duplicate publications were excluded. If relevant articles could not be accessed via the Internet, authors were contacted directly. Given that this was a nonclinical study, institutional review board approval was not sought.

Methodological Quality and Analysis

The methodological quality of randomized controlled or comparative trials (RCTs) was appraised with reference to the National Health and Medical Research Council Guidelines2 and Consolidated Standards of Reporting Trials (CONSORT) statement.3 All data were extracted by the author. Marked heterogeneity of study design and outcome measures precluded statistical pooling of results for meta-analysis, hence a descriptive summary of the findings is presented.

Results

Literature Search

The initial PubMed literature search identified 849 items published since 1999, with 50 relevant studies (34 clinical, 16 nonclinical) included in the review. An additional 35 relevant studies (21 clinical, 14 nonclinical) were retrieved in a broader PubMed search or from other databases. Thus, in total, 85 new studies (55 clinical, 30 nonclinical) were reviewed. Articles were most often excluded because they did not study the population and/or intervention of interest (Fig 1).

Systematic Reviews

Twelve systematic literature reviews were identified. Their characteristics, including a summary of their results and conclusions, are shown in Table 1.4‐15 In contrast to the current review, which covers a wide range of ICU physiotherapy practices, these reviews focused on specific areas of physiotherapy practice in the ICU, with the most frequent topic being the early mobilization and rehabilitation of patients in the ICU.4‐10 Despite only limited data being available, most concluded that early mobilization and rehabilitation are safe and effective in the ICU setting, although further research is required to confirm and extend its role.4‐10

Mobilization of critically ill patients with an emphasis on functional outcomes and patient safety.

15

Evidence from the limited number of studies that have examined the early mobilization of critically ill patients supports early mobilization as a safe and effective intervention that can have a significant impact on functional outcomes.

Variables that have been used to evaluate physiologic responses to mobilization.

17

Most studies that have investigated the mobilization of critically ill patients evaluated cardiopulmonary function. Future studies evaluating the safety and efficacy of mobilization in this setting should measure multiple physiologic variables, including inflammatory biomarkers, and other measures of physiologic function, such as pain, comfort, anxiety, mood, and sleep.

Mobilization can be defined as an interdisciplinary, goal-directed therapy aimed at facilitating movement and improving outcomes in critically ill patients. The concept of mobilization needs further definition with respect to factors such as the activities it comprises, their quantity, intensity, duration, and frequency, and interdisciplinary roles.

The studies reviewed support the ability of mobility interventions to improve the outcomes of patients receiving prolonged mechanical ventilation, but there is limited evidence on how to best accomplish this goal.

There is marked variability between countries in the availability and prescription of mobilization therapy in the ICU setting, with routine mobilization therapy least likely to be available in the United States. The data in support of mobilization therapy for critically ill patients, while of a low level of evidence, are substantial. This justifies a paradigm shift in attitudes toward PT and the prevention of critical illness weakness.

The evidence available regarding the effectiveness of physical training within the ICU environment is limited to patients with long-term respiratory failure who may not be representative of a general critically ill population.

When the rehabilitation of critically ill patients is commenced early during their ICU admission, it leads to a higher rate of PT consultation, and patient-related benefits are seen, such as decreased time to achieve activity milestones, improved functional outcomes at ICU and hospital discharge, and reduced direct patient costs. Early rehabilitation of the critically ill patient, led by PTs, has the potential to dramatically influence recovery and functional outcomes in this vulnerable patient group.

Evidence supporting PT Rxs for patients in the ICU is limited due to the lack of long-term studies. While there is strong evidence to support the use of therapist-driven weaning protocols, further studies with larger sample sizes are needed to evaluate the effectiveness of most PT techniques in the ICU.

MH results in short-term beneficial effects on physiologic endpoints such as respiratory compliance, oxygenation, and airway clearance. However, its effect on broader outcomes, such as duration of mechanical ventilation and ICU LOS, is unknown. MH has been associated with side effects, albeit infrequently. Appropriately powered and methodologically sound studies are needed before it can be recommended for routine use.

Studies have used many different outcomes to measure the function of ICU survivors, including muscle strength, functional tests, and health-related quality of life. In general, the sensitivity and validity of these instruments for use with survivors of a critical illness has not yet been established.

Identify which outcomes should be measured in the adult critical care environment and which outcomes PTs are currently including in research reports.

35

Research that has investigated the efficacy of PT in ICU has primarily measured physiologic variables or provided descriptions of current practice, without linking these to broader outcomes such as functional status and health-related quality of life. Further work is needed to develop and refine patient-centered and economic measurements that will be sufficiently sensitive to be able to measure the effect of PT service provision in ICU.

Data concerning the effectiveness of PT and OT for patients in the ICU with traumatic brain injury are very limited, making it impossible to offer clear, evidence-based recommendations. Respiratory PT has not been shown to be effective for the prevention or Rx of VAP. The efficacy of other PT and OT interventions must still be demonstrated.

Indicates the number of articles in the reference list (number of studies included in review not specifically stated).

Clinical Trials: Study and Patient Characteristics

The clinical trials reviewed evaluated a variety of physiotherapy interventions, including multimodality respiratory physiotherapy, mobilization, inspiratory muscle training (IMT), and neuromuscular electrical stimulation (NMES). For the sake of clarity, study findings are presented according to the intervention evaluated.

Multimodality Respiratory Physiotherapy:

Eighteen clinical trials were identified that evaluated the effectiveness of multimodality respiratory physiotherapy, with the interventions studied including various combinations of positioning, manual hyperinflation (MH), ventilator hyperinflation (VH), chest wall vibrations, and rib-cage compression.16‐33 The characteristics and main findings of these 18 studies are shown in Table 2 (sorted according to methodological quality and sample size). There were five RCTs,16‐20 nine randomized crossover trials,21‐29 one systematically allocated controlled trial,30 one historical controlled trial,31 and two observational studies.32,33

A regular respiratory PT regimen in addition to routine medical/nursing care did not significantly decrease the incidence of VAP, duration of mechanical ventilation or ICU LOS in adults with acquired brain injury.

Rx: as for control plus respiratory PT, including positioning, MH, suction, 6 times/d.

Significant changes observed in Paco2 and compliance over time for all three groups (Paco2 increased, compliance decreased 10-min post-Rx). Pao2/Fio2 and Svo2 did not significantly change in any group. Svo2 was significantly lower in group 2. HR and BP showed significant, but not clinically important, changes over time.

Disconnection of patients with ALI from mechanical ventilation for PT Rx can result in significant derecruitment of the lungs and altered physiology. The use of MH does not appear to override the loss of PEEP and the derecruitment effects.

Group 2: as for group 1, then positioned (L and R flat side lying), suction.

Significantly higher airway pressure with MH than VH. No significant difference between Rxs for other outcomes.

VH was as safe and effective during respiratory PT Rx as MH, when applied with the same parameters and precautions. VH has potential advantages over MH, the biggest being that no ventilator circuit disconnection is required.

Significantly greater increase in compliance for MH Rx. Significant decrease in airway resistance 30-min post-MH Rx but not control Rx.

Suction alone did not cause deterioration in compliance and airway resistance and can probably be used safely in patients with VAP. The addition of MH improved respiratory mechanics compared with suction alone.

VH promoted greater improvements in respiratory mechanics with less metabolic disturbance than MH. Other variables such as sputum production, hemodynamics and oxygenation were affected similarly by both techniques.

Four of the five RCTs were well designed and involved samples of at least 101 patients.16‐19 Study populations comprised patients who were intubated and mechanically ventilated after cardiac surgery,16 mechanically ventilated > 48 h,17,19 or mechanically ventilated with acquired brain injury.18 Patients were prospectively randomly allocated to a control group (usually receiving standard medical/nursing care) or a treatment group that received additional multimodality respiratory physiotherapy (comprising a combination of techniques such as positioning, MH, with or without chest wall vibrations). Frequency of this additional multimodality respiratory physiotherapy was as clinically indicated in two studies,16,17 bid,19 and six times a day.18 Medium-term clinical outcomes such as duration of intubation, incidence of ventilator-associated pneumonia (VAP), and length of stay (LOS) in the ICU and hospital were measured. Two of the four RCTs found no significant difference between groups for any outcomes,16,18 one found that the median time for 50% of patients to become ventilator-free was significantly longer in the treatment group,17 and the final study favored the treatment group, with significant benefits seen in terms of the clinical pulmonary infection score, ventilator weaning and mortality rates.19 The fifth RCT was methodologically compromised by a small sample size (n = 17) that was further compromised by division into three treatment groups.20

The nine randomized crossover trials all had comparatively small sample sizes (n ≤ 46) and prospectively evaluated the physiologic effects of individual respiratory physiotherapy interventions.21‐29 Six of the randomized crossover trials evaluated MH.21,25‐29 Three of these compared MH to VH, when added to a treatment of positioning and suction, with all finding that VH was as effective as MH for outcomes such as sputum clearance and respiratory compliance.21,26,29 Two studies investigated the addition of MH to a treatment of positioning and suction, with both finding that MH was associated with short-term beneficial physiologic effects such as improved respiratory compliance.27,28 Hodgson et al25 compared two different circuits for delivering MH, finding that while MH with a Mapleson C circuit cleared significantly more sputum than MH with a Laerdal circuit, this did not have any consequences in terms of oxygenation or respiratory compliance. Two randomized crossover trials evaluated the effect of expiratory rib-cage compression, finding that it did not add to the effectiveness of positioning and suction in terms of oxygenation, respiratory compliance, or sputum clearance.22,23 Finally, Berney et al,24 investigating 20 patients who were mechanically ventilated, found that the addition of a head-down tilt to MH, rather than flat side lying, increased the weight of sputum cleared.

A prospective, systematically allocated, controlled trial involving 60 patients who were mechanically ventilated was undertaken by Ntoumenopoulos et al.30 While the incidence of VAP was significantly lower in a group that received multimodality respiratory physiotherapy bid compared with a control group, duration of mechanical ventilation, ICU LOS and mortality were not significantly different between groups.

A large historical controlled trial by Malkoç et al31 (n = 501) found that a group that received multimodality respiratory physiotherapy had a significantly shorter duration of mechanical ventilation and ICU LOS than a historical control group. However, as the treatment group also received mobilization, it is not clear which components of therapy were effective.

From the two prospective observational studies, Thomas et al32 found that lateral positioning had no significant effect on oxygenation of 34 patients on mechanical ventilation and Clarke et al,33 studying 25 patients on mechanical ventilation, reported that manual hyperventilation can result in higher inflation pressures in patients with susceptible lungs.

Mobilization:

For the purposes of this review, the definition of mobilization provided by Stiller1 has been used, whereby mobilization is a broad term that encompasses active limb exercises, actively moving or turning in bed, sitting on the edge of the bed, sitting out of bed in a chair (via mechanical lifting machines, slide board, or standing transfer), standing, and walking. Twenty-six clinical trials were identified that evaluated the use of mobilization interventions.34‐59Table 3 summarizes their characteristics. There were three RCTs,34‐36 five nonrandomized controlled trials,37‐41 one historical controlled study,42 and 17 observational studies.43‐59

Return to independent functional status at hospital DC occurred in significantly more Rx group patients. Duration of delirium and mechanical ventilation significantly shorter in Rx group. Ventilator-free days, and ICU and hospital LOS not significantly different between groups. Serious adverse events: 0.2%.

Sedation interruption and PT/OT in the earliest days of critical illness was safe and well tolerated, resulted in better functional outcomes at hospital DC, shorter duration of delirium, and more ventilator-free days.

Proportion receiving ICU PT, days until first out of bed, ventilator days, ICU and hospital LOS, adverse events.

ICU PT provided to significantly more patients in Rx group. Rx group first out of bed significantly earlier. ICU and hospital LOS significantly shorter in Rx group. Ventilator days not significantly different between groups. Serious adverse events: 0%.

Implementation of an early mobility protocol by a mobility team resulted in more PT sessions and was associated with a shorter LOS for hospital survivors.

Rapid shallow breathing index did not significantly change. BI significantly improved over time in Rx group (not clear what happened to control). Weaning success rate higher in Rx group (significance not stated).

Respiratory muscle and limb strength significantly increased at 3 and 6 wk in Rx group but not control group. BI and FIM scores significantly higher in Rx group than control group at 3 and 6 wk. Ventilator-free time increased significantly in Rx group but not control group at 6 wk.

A 6-wk physical training program may improve limb muscle strength and ventilator-free time and improve functional outcomes in patients requiring prolonged mechanical ventilation.

Standing significantly increased rib cage displacement, Vt, RR, and V.e. No further significant changes seen with walking. BP and HR significantly increased when the patients sat on edge of bed. Pao2 and Paco2: no significant change.

Changes in Vt, RR, and V.e during mobilization were largely due to positional change from supine to standing.

The largest prospective RCT, by Schweickert et al,34 involved 104 patients who had been mechanically ventilated for < 72 h and were likely to require ventilation for a further 24 h. The patients were randomly allocated to receive daily sedative interruption followed by therapy that concentrated on mobilization activities (eg, range of motion exercises, functional tasks, sit/stand/walk) or daily sedative interruption and standard medical/nursing care. Compared with the control group, the treatment group demonstrated a significantly shorter duration of delirium and mechanical ventilation, and significantly more patients in the treatment group achieved an independent functional status at hospital discharge. The second prospective RCT, involving 90 patients whose ICU LOS was anticipated as being > 7 days, investigated the effectiveness of adding cycling exercise using a bedside cycle ergometer to a standard physiotherapy mobilization regimen (ie, limb exercises, walk).35 While no significant differences were found between groups at ICU discharge, the treatment group achieved significantly higher distances in the 6-min walk test than the control group at hospital discharge and their quadriceps strength improved significantly between ICU and hospital discharge. The third RCT, by Chang et al,36 prospectively investigated the effect of sitting out of bed (for at least 30 min, most often on a daily basis) on the respiratory muscle strength of 34 patients over a 6-day study period. The patients in the control group were positioned supine or semirecumbent in bed. No significant differences were seen between groups.

Two of the five nonrandomized controlled studies prospectively allocated patients to a control group (standard medical/nursing care) or a treatment group (progressive mobilization [eg, limb exercises, sit/stand/walk]).37,41 Despite marked differences in sample size (n = 33037; n = 3241), both demonstrated advantages for the treatment group, including significantly better functional ability, which translated into benefits such as a significantly shorter ICU and hospital LOS. Two nonrandomized controlled studies prospectively compared a control phase, where patients received standard medical/nursing care, to a treatment phase following the introduction of a progressive mobilization program.39,40 Needham et al40 demonstrated benefits following implementation of the mobilization program (which included reduced sedation), including significantly better functional mobility in the ICU and significantly shorter ICU and hospital LOS. Similarly, Winkelman et al39 found that the ICU LOS was significantly shorter after implementation of a progressive mobilization program, although no significant difference was found for duration of mechanical ventilation. Yang et al38 found that progressive mobilization enhanced the success rate of ventilator weaning.

Bassett et al42 compared outcomes between a historical controlled group, where data were collated retrospectively, and a treatment group after the implementation of an early mobilization program across 13 ICUs. While details are scarce, no significant differences were seen between the two groups for outcomes such as the length of mechanical ventilation, and ICU and hospital LOS.

The 17 observational studies recorded outcomes regarding the feasibility, safety, and physiologic effects of mobilization on patients in the ICU.43‐59 Overall, mobilization activities were found to be feasible and safe, although associated at times with short-term changes in physiologic parameters, with the frequency of serious adverse events ≤ 1%. Garzon-Serrano et al47 prospectively compared the level of mobility achieved for 63 patients in the ICU according to whether mobilization was performed by nursing or physical therapy staff, finding that physical therapists mobilized patients to a significantly higher level than nursing staff. Barriers to the mobilization of patients in the ICU that were identified included the ICU culture,44 sedation,48 limited rehabilitation staffing,48 and patients being medically unfit.50 Skinner et al56 developed a clinical exercise outcome measure for use in the ICU, namely, the physical function ICU test (PFIT), finding it easy to use, responsive, and reliable in a study of 12 patients in the ICU.

Inspiratory Muscle Training:

Five clinical trials were found that evaluated the effectiveness of IMT in the ICU.60‐64 These studies are summarized in Table 4. There were two RCTs,60,61 two case series,62,63 and one single case report.64

Acute subgroup: muscle thickness significantly decreased over time in both groups, no significant difference between groups. Long-term subgroup: muscle thickness significantly increased over time in Rx group but not control group, thickness significantly greater in Rx group at 4 wk.

NMES could be an effective adjunct in ICU to reverse muscle wasting in long-term patients.

Cader et al,60 in a well-designed prospective RCT involving 41 elderly patients who were mechanically ventilated for > 48 h due to type 1 respiratory failure, found that daily progressive IMT using a threshold training device was associated with significant benefits (eg, shorter weaning time) compared with a control group. In contrast, the prospective RCT by Caruso et al,61 whose study sample comprised 25 patients likely to require mechanical ventilation > 72 h, found that IMT using the trigger sensitivity on the ventilator did not have significant benefits in terms of weaning duration or rate of reintubation.

Threshold IMT was found to be effective in terms of weaning ventilator-dependent patients in the case series by Sprague and Hopkins63 involving six patients, and a single case study by Bissett and Leditschke.64 Bissett et al,62 in another case series, evaluated the safety of IMT, with no deleterious effects on physiologic parameters or clinically important adverse effects recorded.

Neuromuscular Electrical Stimulation:

Three clinical studies, summarized in Table 4, were identified that evaluated the effectiveness of NMES.65‐67 There were two prospective, stratified RCTs65,66 and one within-subject RCT.67

The RCT by Routsi et al65 involved 52 critically ill patients, stratified according to age and sex, and evaluated the effect of daily NMES to the quadriceps and peroneous longus muscles. They demonstrated a significantly lower incidence of critical-illness polyneuromyopathy and reduced weaning time in the treatment group. The stratified RCT by Gruther et al66 allocated 33 patients to a daily session of NMES to the quadriceps muscle or a sham treatment, with the sample stratified according to ICU LOS. While no significant difference was seen between the treatment and sham groups for short-stay patients (< 7 days), longer-term patients (> 14 days) who received NMES had a significant increase in muscle thickness at 4 weeks, whereas the sham group had no significant change in muscle thickness. The within-subject RCT by Poulsen et al,67 involving eight male patients in the ICU with septic shock, found no significant difference in quadriceps muscle volume between patients’ control and treatment sides after 7 days.

Other Clinical Trials:

Three other clinical trials that investigated physiotherapy interventions in the ICU are summarized in Table 4.68‐70 Zeppos et al68 documented a low incidence of adverse physiologic effects associated with all physiotherapy interventions in the ICU; De Freitas69 found that patients who received physiotherapy were predominantly male, elderly, nonsurgical, and with high disease severity and mortality; and Clavet et al70 reported that patients with joint contractures in the ICU had a significantly longer ICU LOS and lower ambulatory level at the time of hospital discharge than those without joint contractures.

Nonclinical Studies: Study and Sample Characteristics

Expert Opinion:

Three articles, summarized in Table 5, provided expert opinions regarding the role of physiotherapy in the ICU.71‐73 Gosselink et al71 summarized the findings of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on the effectiveness of physiotherapy for acute and chronic critically ill patients. Despite noting a lack of high-level evidence, they identified the following evidence-based targets for physiotherapy: deconditioning, muscle weakness, joint stiffness, impaired airway clearance, atelectasis, intubation avoidance, and weaning failure. The two studies by Hanekom et al72,73 used a Delphi process to develop evidence-based clinical management algorithms for the prevention, identification, and management of pulmonary dysfunction in intubated patients in the ICU and for the early physical activity and mobilization of critically ill patients.

Clinical management algorithm for the early mobilization of critically ill patients.

The panelists concluded that an individual mobilization plan must be developed for each patient admitted to an ICU, and made a case that early physical activity and mobilization should be the foundation pillars of PT management in ICU.

Current PT practices for patients recovering from critical illness in the US.

PT was commonly administered to patients in the ICU during their recovery. 89% required medical referral to initiate PT. The frequency and type of intervention varied based on hospital type and the clinical scenario.

92% routinely treated ventilated, sedated patients in ICUs. Of these, 99% used passive movements routinely and 78% performed passive movements daily. Joints most commonly treated were the shoulder, hip, knee, elbow, and ankle, for a median of 5 times per area, and joints were taken to the end of ROM. 78% monitored the effects of passive movements, with HR and BP most frequently monitored.

35% routinely assessed passive limb ROM of all patients in the ICU. 14% routinely provided passive limb exercises as a Rx for all patients in the ICU. Prescription of passive limb ROM exercises was variable between respondents.

91% used MH as a Rx technique. 76% used MH as a routine Rx for ventilated patients. There was strong agreement between respondents on the components of MH, preferred Rx positions, contraindications, and perceived benefits. There was considerable variation between respondents in the duration, number of breaths, and circuits used when performing MH.

ERS = European Respiratory Society; ESICM = European Society of Intensive Care Medicine; NZ = New Zealand; UK = United Kingdom; US = United Statesct. See Table 1‐4 legends for expansion of other abbreviations.

Surveys:

A total of 15 surveys (Table 5) were identified that evaluated physiotherapy interventions in the ICU.74‐88 Sample sizes ranged from 3288 to 482;74 most samples comprised physiotherapists alone,74‐76,78‐81,84‐86,88 two included physiotherapists and nursing staff,82,83 one study included ICU directors and physiotherapists,77 and the last included patients in the ICU.87 All studies used purpose-designed surveys. Topics surveyed were general physiotherapy service provision,74,79,80,82,85 use of passive movements,75,86 rehabilitation and exercise prescription,78 positioning,83 VH,76,84 MH,88 use of tilt tables,81 ICU directors’ perceptions of their physiotherapy service,77 and patient satisfaction with the ICU physiotherapy service.87 The findings of each study are summarized in Table 5.

Discussion

This systematic review updates a summary of the research evidence concerning the effectiveness of physiotherapy in the ICU published in 2000. A total of 85 new studies (55 clinical and 30 nonclinical) were reviewed.

The most striking change in the evidence base since the review published by Stiller in 20001 has been the advent and growth of research, particularly in the last 5 years, evaluating the use of early progressive mobilization. In contrast to 2000, when no studies were identified, the current review included 26 clinical studies on this topic and, while study quality was variable, statistically significant and clinically important benefits resulting from early mobilization were demonstrated. These new clinical studies have shown that early progressive mobilization is feasible and safe, and results in significant functional benefits that may translate into positive effects on the ICU and hospital LOS. Stiller1 noted that the role of physiotherapy in the ICU would continue to be questioned until physiotherapy has been shown to have a favorable impact on broader outcomes of patients in the ICU. The new evidence demonstrating the beneficial effects of mobilization on broader outcomes such as the ICU and hospital LOS confirms an unquestionable role for physiotherapy in the ICU. Given that the demand for physiotherapy services often outstrips the resources available, and the new evidence demonstrating the effectiveness of physiotherapy interventions aimed at early mobilization, ICU physiotherapists should give priority to interventions aimed at early progressive mobilization. To be successful, implementation of early progressive mobilization relies on an ICU culture that considers mobilization an essential part of multidisciplinary care. Safety guidelines and protocols for progressive mobilization of patients in the ICU are available.34,37,42,47,89

Eighteen new clinical trials were identified that evaluated the effectiveness of multimodality respiratory physiotherapy for adult, intubated, mechanically ventilated patients in the ICU. The results of these trials support and extend the conclusions made by Stiller in 2000,1 namely, that multimodality respiratory physiotherapy may result in short-term improvements in pulmonary function. While there is some new evidence from RCTs that the provision of routine multimodality respiratory physiotherapy can impact positively on outcomes such as duration of intubation and the ICU LOS, there is, however, a similar amount of new high-quality evidence suggesting that it may not. In terms of specific respiratory physiotherapy interventions, there is limited evidence from new randomized crossover trials suggesting that expiratory rib-cage compression is ineffective and that MH may have beneficial short-term effects on respiratory compliance, concurring with the conclusions made in the 2000 review.1 New evidence has emerged demonstrating that VH is as effective as MH. There is new high-quality evidence concerning the effectiveness of IMT for patients in the ICU; however, this evidence is scarce, hence the routine or selective use of IMT for patients in the ICU cannot be recommended at present. Similarly, the evidence that has been published since 1999 concerning the effectiveness of NMES is limited and, thus, clinical recommendations regarding its use in ICU cannot be made.

Limitations of this systematic review included the variable methodological quality of the studies. The diverse range of study samples and study methodology precluded pooling of results and statistical analysis. The interventions that were provided usually comprised numerous components, making it impossible to determine the effectiveness of individual treatment components.

A strength of this literature review was the inclusion of all clinical studies that have evaluated physiotherapy for adult patients in the ICU, irrespective of study design. Additionally, by reviewing the evidence concerning a broad range of physiotherapy practice, rather than focusing on one specific type of intervention (eg, multimodality respiratory physiotherapy or mobilization alone), it has been possible to highlight the emerging evidence concerning the beneficial effects of early progressive mobilization compared with other physiotherapy interventions.

Conclusions

In summary, the evidence concerning the efficacy of routine multimodality respiratory physiotherapy for adult, intubated patients receiving mechanical ventilation remains unclear. There is strong, albeit limited, evidence published since the review in 2000 showing that physiotherapy intervention focusing on early progressive mobilization is feasible and safe, and results in significant functional benefits, which may translate into a reduced ICU and hospital LOS. This emerging evidence confirms the role of the physiotherapist in ICU and highlights that early progressive mobilization is an effective area of physiotherapy clinical practice for adult, intubated, mechanically ventilated patients. Further research to confirm the efficacy of early progressive mobilization is required, in particular to determine the optimal “dosage” in terms of its most effective components, intensity, duration, and frequency.

Acknowledgments

Author contributions: Dr Stiller had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Stiller: contributed to the literature search, identification of relevant studies, data extraction, analysis of the results, and writing of the paper.

Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: The author would like to thank Alisia Jedrzejczak, BPhysio (Hons), and Kate Roberts, BAppSc (Physio), BSc, for their helpful comments regarding this paper.

Hanekom S, Gosselink R, Dean E, et al. The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: synthesis of evidence and expert opinion and its translation into practice. Clin Rehabil. 2011;25(9):771-787. [CrossRef][PubMed]

Mobilization of critically ill patients with an emphasis on functional outcomes and patient safety.

15

Evidence from the limited number of studies that have examined the early mobilization of critically ill patients supports early mobilization as a safe and effective intervention that can have a significant impact on functional outcomes.

Variables that have been used to evaluate physiologic responses to mobilization.

17

Most studies that have investigated the mobilization of critically ill patients evaluated cardiopulmonary function. Future studies evaluating the safety and efficacy of mobilization in this setting should measure multiple physiologic variables, including inflammatory biomarkers, and other measures of physiologic function, such as pain, comfort, anxiety, mood, and sleep.

Mobilization can be defined as an interdisciplinary, goal-directed therapy aimed at facilitating movement and improving outcomes in critically ill patients. The concept of mobilization needs further definition with respect to factors such as the activities it comprises, their quantity, intensity, duration, and frequency, and interdisciplinary roles.

The studies reviewed support the ability of mobility interventions to improve the outcomes of patients receiving prolonged mechanical ventilation, but there is limited evidence on how to best accomplish this goal.

There is marked variability between countries in the availability and prescription of mobilization therapy in the ICU setting, with routine mobilization therapy least likely to be available in the United States. The data in support of mobilization therapy for critically ill patients, while of a low level of evidence, are substantial. This justifies a paradigm shift in attitudes toward PT and the prevention of critical illness weakness.

The evidence available regarding the effectiveness of physical training within the ICU environment is limited to patients with long-term respiratory failure who may not be representative of a general critically ill population.

When the rehabilitation of critically ill patients is commenced early during their ICU admission, it leads to a higher rate of PT consultation, and patient-related benefits are seen, such as decreased time to achieve activity milestones, improved functional outcomes at ICU and hospital discharge, and reduced direct patient costs. Early rehabilitation of the critically ill patient, led by PTs, has the potential to dramatically influence recovery and functional outcomes in this vulnerable patient group.

Evidence supporting PT Rxs for patients in the ICU is limited due to the lack of long-term studies. While there is strong evidence to support the use of therapist-driven weaning protocols, further studies with larger sample sizes are needed to evaluate the effectiveness of most PT techniques in the ICU.

MH results in short-term beneficial effects on physiologic endpoints such as respiratory compliance, oxygenation, and airway clearance. However, its effect on broader outcomes, such as duration of mechanical ventilation and ICU LOS, is unknown. MH has been associated with side effects, albeit infrequently. Appropriately powered and methodologically sound studies are needed before it can be recommended for routine use.

Studies have used many different outcomes to measure the function of ICU survivors, including muscle strength, functional tests, and health-related quality of life. In general, the sensitivity and validity of these instruments for use with survivors of a critical illness has not yet been established.

Identify which outcomes should be measured in the adult critical care environment and which outcomes PTs are currently including in research reports.

35

Research that has investigated the efficacy of PT in ICU has primarily measured physiologic variables or provided descriptions of current practice, without linking these to broader outcomes such as functional status and health-related quality of life. Further work is needed to develop and refine patient-centered and economic measurements that will be sufficiently sensitive to be able to measure the effect of PT service provision in ICU.

Data concerning the effectiveness of PT and OT for patients in the ICU with traumatic brain injury are very limited, making it impossible to offer clear, evidence-based recommendations. Respiratory PT has not been shown to be effective for the prevention or Rx of VAP. The efficacy of other PT and OT interventions must still be demonstrated.

A regular respiratory PT regimen in addition to routine medical/nursing care did not significantly decrease the incidence of VAP, duration of mechanical ventilation or ICU LOS in adults with acquired brain injury.

Rx: as for control plus respiratory PT, including positioning, MH, suction, 6 times/d.

Significant changes observed in Paco2 and compliance over time for all three groups (Paco2 increased, compliance decreased 10-min post-Rx). Pao2/Fio2 and Svo2 did not significantly change in any group. Svo2 was significantly lower in group 2. HR and BP showed significant, but not clinically important, changes over time.

Disconnection of patients with ALI from mechanical ventilation for PT Rx can result in significant derecruitment of the lungs and altered physiology. The use of MH does not appear to override the loss of PEEP and the derecruitment effects.

Group 2: as for group 1, then positioned (L and R flat side lying), suction.

Significantly higher airway pressure with MH than VH. No significant difference between Rxs for other outcomes.

VH was as safe and effective during respiratory PT Rx as MH, when applied with the same parameters and precautions. VH has potential advantages over MH, the biggest being that no ventilator circuit disconnection is required.

Significantly greater increase in compliance for MH Rx. Significant decrease in airway resistance 30-min post-MH Rx but not control Rx.

Suction alone did not cause deterioration in compliance and airway resistance and can probably be used safely in patients with VAP. The addition of MH improved respiratory mechanics compared with suction alone.

VH promoted greater improvements in respiratory mechanics with less metabolic disturbance than MH. Other variables such as sputum production, hemodynamics and oxygenation were affected similarly by both techniques.

Return to independent functional status at hospital DC occurred in significantly more Rx group patients. Duration of delirium and mechanical ventilation significantly shorter in Rx group. Ventilator-free days, and ICU and hospital LOS not significantly different between groups. Serious adverse events: 0.2%.

Sedation interruption and PT/OT in the earliest days of critical illness was safe and well tolerated, resulted in better functional outcomes at hospital DC, shorter duration of delirium, and more ventilator-free days.

Proportion receiving ICU PT, days until first out of bed, ventilator days, ICU and hospital LOS, adverse events.

ICU PT provided to significantly more patients in Rx group. Rx group first out of bed significantly earlier. ICU and hospital LOS significantly shorter in Rx group. Ventilator days not significantly different between groups. Serious adverse events: 0%.

Implementation of an early mobility protocol by a mobility team resulted in more PT sessions and was associated with a shorter LOS for hospital survivors.

Rapid shallow breathing index did not significantly change. BI significantly improved over time in Rx group (not clear what happened to control). Weaning success rate higher in Rx group (significance not stated).

Respiratory muscle and limb strength significantly increased at 3 and 6 wk in Rx group but not control group. BI and FIM scores significantly higher in Rx group than control group at 3 and 6 wk. Ventilator-free time increased significantly in Rx group but not control group at 6 wk.

A 6-wk physical training program may improve limb muscle strength and ventilator-free time and improve functional outcomes in patients requiring prolonged mechanical ventilation.

Standing significantly increased rib cage displacement, Vt, RR, and V.e. No further significant changes seen with walking. BP and HR significantly increased when the patients sat on edge of bed. Pao2 and Paco2: no significant change.

Changes in Vt, RR, and V.e during mobilization were largely due to positional change from supine to standing.

Acute subgroup: muscle thickness significantly decreased over time in both groups, no significant difference between groups. Long-term subgroup: muscle thickness significantly increased over time in Rx group but not control group, thickness significantly greater in Rx group at 4 wk.

NMES could be an effective adjunct in ICU to reverse muscle wasting in long-term patients.

Clinical management algorithm for the early mobilization of critically ill patients.

The panelists concluded that an individual mobilization plan must be developed for each patient admitted to an ICU, and made a case that early physical activity and mobilization should be the foundation pillars of PT management in ICU.

Current PT practices for patients recovering from critical illness in the US.

PT was commonly administered to patients in the ICU during their recovery. 89% required medical referral to initiate PT. The frequency and type of intervention varied based on hospital type and the clinical scenario.

92% routinely treated ventilated, sedated patients in ICUs. Of these, 99% used passive movements routinely and 78% performed passive movements daily. Joints most commonly treated were the shoulder, hip, knee, elbow, and ankle, for a median of 5 times per area, and joints were taken to the end of ROM. 78% monitored the effects of passive movements, with HR and BP most frequently monitored.

35% routinely assessed passive limb ROM of all patients in the ICU. 14% routinely provided passive limb exercises as a Rx for all patients in the ICU. Prescription of passive limb ROM exercises was variable between respondents.

91% used MH as a Rx technique. 76% used MH as a routine Rx for ventilated patients. There was strong agreement between respondents on the components of MH, preferred Rx positions, contraindications, and perceived benefits. There was considerable variation between respondents in the duration, number of breaths, and circuits used when performing MH.

ERS = European Respiratory Society; ESICM = European Society of Intensive Care Medicine; NZ = New Zealand; UK = United Kingdom; US = United Statesct. See Table 1‐4 legends for expansion of other abbreviations.

Hanekom S, Gosselink R, Dean E, et al. The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: synthesis of evidence and expert opinion and its translation into practice. Clin Rehabil. 2011;25(9):771-787. [CrossRef][PubMed]

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